Mark Briesacher, MD: Hi. This is Mark Briesacher, I'm the Chief Physician Executive at Intermountain Healthcare, and I'm sitting here today with Dr. Hugh West, who is the medical director of the musculoskeletal clinical program at Intermountain, and Dr. Paul Krakovitz, who is the Associate Chief Medical Officer for specialty based care. So, Hugh, I was thinking about ... we met many years ago, but I think the point in time where we really started to get to know each other was that day I spent with you in clinic when, on your urging, you said, "Hey come and watch what we do here because we're doing something different." And in fact, you were then, and still are today, doing something different.

So I was wondering if we could start with maybe you talking about this model that you developed over the years and how it makes care better for patients, safer for patients, and leads to great outcomes for them.

Hugh West, MD: Yeah. Thanks for giving us the opportunity to talk with you about what our vision is for musculoskeletal care in the system. We feel really strongly about this and really feel there's just so much area for improvement, but I remember really well when you visited us a few years ago, and for a long time now, I've felt really strongly that care of a patient is really a team event and that you can't just have a doctor and a patient be the sum total of what that care process is. And in orthopedic surgery and musculoskeletal medicine in general, there are many different care providers that impact on the care of a patient, and most commonly, they're disconnected from each other. They don't communicate well with each other.

We have people with great care and diagnostic sophistication that can be part of the conversation that are excluded from the conversation, and I also feel like there's just a dynamic in terms of how patients access surgical care, which is obviously a high cost event and a risky event in the life of a patient. Where the ... that moment in time where that decision is made between a surgeon and a patient is inherently fraught with bias. You have a frustrated patient, who desires to have a problem solved, you have a physician who is hurried and confident. You put those together in a hospital environment where they invite your productivity and suddenly you have a formula for utilization, perhaps, in directions that could be sent down another pathway that could be safer and less expensive and in fact, better for the patient.

So bringing these different members of a team into that moment of conversation with the patient really gives the patients other options, which they sometimes can't even be aware of, and I just think it's a wonderful opportunity for us to address all of these issues of quality and cost and patient experience in a much more meaningful way.

Mark Briesacher, MD: It strikes me that the involving the patient more in that decision making process around, "What are my treatment options and what is the best thing for me?" It actually helps us in several ways. One, they make a more informed decision, and two, they are more engaged in their care because so much of the care, especially in the post-operative period is really dependent on the patient doing their part of self-care.

Hugh West, MD: Yes. Absolutely.

Mark Briesacher, MD: So Hugh, why don't you describe your team and who's on it, and if I were a family medicine physician practicing in Taylorsville or practicing in Utah County, down in St. George or up in Logan, how would I get one of my patients, who is really struggling with knee osteoarthritis into that team?

Hugh West, MD: Yeah. That's a great question. And the way we have modeled this in our practice, which is not entirely typical, is it begins with the first phone call that the patient makes to access the system. And I would say right now, we have opportunity to create better referral lines that are more institutionally based and not necessarily physician brand based, but the way it works right now is that patients sort of search out through contacts or whatever information they have access to, who do I think I would trust to care for me? And they call my office, for example. So the person who answers the phone actually has to set a different expectation than they were anticipating, and they are basically persuaded in that moment that they shouldn't see me first. That actually, they will have a richer consultation, a more relaxed, more open-ended consultation of discovery and education by not seeing me.

Let's be honest, I'm a busy surgeon. I have a surgeon mentality that likes to get to decisions quickly. We work off preconceptions and support those preconceptions as soon as we meet the patient, and all of that I think can get us off on a path that is not necessarily in the patient's interest. So we have involved physical therapists in this role, and it takes a great deal of mentoring. The therapist that works with me now has worked with me for seven or eight years. In her own right, she is a sophisticated diagnostician for that set of conditions that I treat, and they have an open-ended ... not totally open-ended, but a generous time with her, and even though it's not what they expected, they come away from it feeling converted to the model because they realize even though they shouldn't see me after that visit, they are off to see the person who is exactly appropriate for their care.

Mark Briesacher, MD: So this model, is it ... I know it's present in your clinic. Are you aware of ... are there other sites that have adopted this, or kind of what is that roll out plan?

Hugh West, MD: Well we have a plan, and there is a lot of institutional inertia that pushes back against it because billing practices so often dictate our behaviors, and we do not have an easy mechanism. We figure out ways to accommodate it, but we do not extract the value to the system financially that we should, given, I think, the value that's being offered to the patient.

Mark Briesacher, MD: So Paul, this kind of comes into your area now. In your role, thinking about how do we deliver amazing orthopedic care across Intermountain so that you're respective of where a patient presents with an orthopedic condition, they're getting best care, safest care, highest quality, great experience, lowest appropriate cost so that the total cost of care for that episode is right where it should be. What do you think some of the important next steps are in this area?

Paul Krakovitz, MD: I think really what we need to do is to continue to educate to the model, and in order to do any model where we're changing the way a paradigm is, we have to teach the providers and we have to teach our patients in the community. So it's working in this direction, showing how this improves the value to the patient, how we can take a patient who thinks they need to undergo a scary surgical procedure, and in the end, they may still require that surgery, but it gets them to the point where they're ready for it and they know they've exhausted all their options. It takes education to get to that point, and it's really starting with the thought leader like Dr. West, to get us to that point.

Mark Briesacher, MD: It strikes me, if I were to put on my primary care hat and think about the 40,000 Medicare Advantage lives that we have full risk for, the 53,000 Medicare ACO lives that we have full risk for, really across all types of insurance, we have almost 600,000 at risk lives, and so the ... while the economics of fee-for-service, they don't really work as well here, certainly the economics of population health, where you are fully accountable for the safe care, the quality care, the experience of care, access to it, and the cost of that care, this model actually is the perfect model both in care of patients and from a healthcare delivery perspective. So how do you think we should talk to our surgeon colleagues about, "Hey, with all of these lives that we have full risk for, what's the best way for us to coordinate the care as we work through conditions like osteoarthritis and hip conditions and low back pain and things like that?"

Hugh West, MD: Yeah. Thanks for that question. We've chosen to approach it at its most fundamental level with the physician culture itself, which we believe that excellence resides in deep specialization, where just having a high volume of similar conditions drives that excellence very, very deeply. So the way we are going about creating that culture, and I know we've spoken about this before, is our aspiration is to meet with every physician in every specialty, everywhere. And we segment them by specialty, and this organically has the effect of driving specialization because you can't choose to show up and engage in every different aspect of orthopedic surgeons, orthopedic surgery. And so we provide what we believe is a gift to them, and our gift to them is a highly organized meeting once a week in an area where they want to be in the conversation.

It's highly pertinent to what they see and do every day. And they're reminded of it every day when they see patients by this event. It begins with a safety event. It's a 45 minute meeting, and it starts on time and it ends on time. It begins with a safety event, or an M and M, that's the first fifteen minutes. The second fifteen minutes is a well prepared didactic Power Point presentation by one of the physicians in the specialty. So they participate, they show up, they teach. And then the third segment, fifteen minutes, is care process development, other business. So we have their attention, and we start out these meetings, and I inevitably think, "Is this going to be a good meeting? Because if it's not, they're not going to show up anymore." And it never fails that we extract meaningful conversation in every one of these meetings, and this is our formula for rapid process turnover.

An improvement event doesn't have to be a yearly goal, it can be a discussion, and even in advance of ... I can give you an example. For example, we had a goal this year to work on VT prophylaxis. Prevention of blood clots and the very bad, serious complication of pulmonary embolism. So we pulled the physicians at the beginning of the year last year, and said, "What's your care process for this?" And the 30 or 40 arthroplasty physicians, we had 30 to 40 different ways of doing it, and over the course of the year and through repeated touches on the subject at the weekly meeting, we came to a consensus of what that care should be. That has not been built into the power plans yet, but just socializing that has reduced the incidence of PE dramatically in a very short period of time.

Mark Briesacher, MD: Alright. So I need to make sure I understand this really clearly. You have orthopedic surgeons taking time out of their day, 45 minutes, they're not seeing patients, they're not doing surgery, they're not making money. You're not paying them to come to the meeting, and yet you have 30 plus knee replacement surgeons ... I don't even know if that's the right number, who gather on a Monday morning to have these conversations?

Hugh West, MD: Exactly.

Mark Briesacher, MD: Why? Why do they come?

Hugh West, MD: Oh they see such value in it. Physicians leave training and they become practitioners in isolation. They become numb to it, but they have a latent hunger for learning. Certainly a hunger to be recognized by their peers and have dialogue with their peers. It really is interesting. We see people sort of on the periphery of our system in outlying geographic areas that don't really ... we don't even know them, and suddenly they're showing up at meetings and they're participating, they're contributing. Our respect as an orthopedic group grows for them. We feel comfortable having them take care of patients instead of saying, "You need to come to Salt Lake to get that care." It has so many benefits at so many levels.

Mark Briesacher, MD: I can confirm that last part about people connecting across great distances because I happen to be up in one of our hospitals that is about as far away as any other hospital, a small critical access hospital, and the number one thing that the orthopedic surgeon there wanted me to know is how valuable he and his physician's assistant found these Monday morning discussions to be. So I ... I also, knowing many of the people that gather on those Monday mornings, you know deep down they absolutely are aligned around safe care, highest quality care, and that's a driver as well.

Paul Krakovitz, MD: Hugh, it really sounds to me like you've got a lot of surgeons who are volunteering their time to learn from one another. What other mechanisms are you using here at Intermountain to help educate fellow surgeons?

Hugh West, MD: Yeah. Good question. Let me just say that these meetings that we have are what we call telepresence meetings. They're virtual meetings. We see their faces, and it's not just a voice on a phone. We feel like, on some level, we get to know them. But we had an event recently, which I thought really illustrates this well. We have a physician in a rural hospital setting who does total joint replacement, and he feels like he does a good job of this, and he's actually a real contributor in the weekly meetings, but we set up a way for him to do a little field trip around the system. He visited three total joint, arthroplasty surgeons, and spent the day in their operating rooms, and he reported on that to us this last Monday morning, and it was really charming.

He began saying, "You know. When I was in second grade, we used to always go on field trips every year." And he said, "I just want to tell you about my field trip in Intermountain." He says, "I've not only gotten to know these people better, which is a valuable experience." He says, "But I learned some really important things, and I can't wait to get back to the operating room to do this particular type of thing better than I was able to do before." It was inspiring, it was bonding I think. I think it was just one more reason to show up, and I think everybody feels that very strongly.

It really speaks to the potential we have as we think about and talk about and become one Intermountain. So moving from multiple groups of knee arthroplasty surgeons to a group of employed and private practice physicians who are affiliated with us through the health plan and through our at-risk network coming together, totally focused on those fundamentals that are important to our patients, as well as the things that are important to them as surgeons and delivering both great care and experiencing that joy in the work that we do. So this is really impressive work. Thank you. And I would say that the institutional support for this, you can only do certain things with big organizations. And I think that Intermountain is playing that role in a really effective way with our domain within musculoskeletal medicine, and we're grateful for it.

Paul Krakovitz, MD: You know what? What really speaks to me with this is that this is a physician who is in a rural community, that doesn't quite see the same volume that we would see here in the valley, and by him being able to come up and learn, he can take that same experience right back to his community. It's just a really nice way for us to be able to continue to give great care across our system.

Mark Briesacher, MD: So Hugh, what's next? What's in the future here for orthopedics and musculoskeletal care? What's ... what ideas have you been thinking about?

Hugh West, MD: Oh, lots. I think that our ... one of our initiatives that we can make progress on, hopefully sooner than later, is how patients access the right provider at the right location. And again, we spoke to this just a little bit, but I think Intermountain can play a very strong role in helping direct patients, whether that's a digital process or a referral center, but where that initial triage has some level of sophistication that gets people in the right place very, very early on in that discussion of their condition. That would be, I think, a near term relatively success that we aspire to.

How we handle trauma care in our system, acute care. And how we ... again, that is a specialty in and of itself with an orthopedic surgeon, but it's sort of more of a, you're tagged with this in the middle of the night and you're caught unprepared, and you have to deliver on a service that you're not really that comfortable with. We can make big improvements on how we handle acute care patients.

And then lastly, I would say, just again, building this culture of team approach to the patient. And there are, again, historical practices that we need to work through to sort of get to that in a healthy way, but we understand what the goal is, and it's very transparent what the vision of what that care experience should be to us, and we have our work to do in getting there. It's a many year project.

Mark Briesacher, MD: Well the one thing I know for sure is that none of this happens without great leadership, so thank you for that, Hugh. Your ideas, your bringing together of your colleagues through developing this comradery, improving care for our patients. I hope you feel really proud about what you and your team is doing.

Intermountain Healthcare is a Utah-based, not-for-profit system of 24 hospitals (includes "virtual" hospital), a Medical Group with more than 2,400 physicians and advanced practice clinicians at about 160 clinics, a health plans division called SelectHealth, and other health services. Helping people live the healthiest lives possible, Intermountain is widely recognized as a leader in clinical quality improvement and efficient healthcare delivery.